Follow-up is key to sustaining improved services
Encouraging signs of a new approach

Follow-up is key to sustaining improved services

Morogoro Rural District has been implementing various activities that are in their district health plans and much interest has been placed on how the districts could implement their plans and the challenges they could face in the process of translating the district health plans into delivery of the services.

Among the district priorities for the past two years was the Integrated Management of Childhood Illnesses (IMCI) approach. This approach being one of the well-defined interventions in terms of implementation guidelines has been going on in the district since March 1997. Training activities took place in this district and by the end of November 1998, 93 per cent of all health facilities in the district had at least one health worker trained in IMCI.

Follow up of trained health workers was also planned to take place as the training plan was being implemented. The aim was to support the trained health workers to start practicing the IMCI skills in their health facilities with the goal of reducing childhood illnesses in the district. The approach is aimed at improving management of sick children within and dependent on the existing health delivery system.

After one year it was noted that only 60% of trained health workers were followed up. It was also found that regular supervision was being done with great difficulties.

Since the two activities are complementary, with the regular supervision activity being crucial in sustaining any intervention in the district, there was an interest to look into how best the district could address this problem and sustain the process of improving the delivery of health services through the strengthening supervision in the district.

The 5th session for follow-up after training took place in December 1998. This session was different from the previous ones because both follow-up after training and regular supervision issues were being addressed at the same time.

How it was done

One day for preparations was set aside in order to orientate all the supervisors on the regular and specific tasks they needed to perform during the supervision process. Tools used included, follow up after training forms, district supervision forms, and supervision checklist developed by the PHC being used in Tanga.Three groups of supervisors were formed. The routes and corresponding number of health facilities to supervise were determined and allocated for each group.

Achievements

There is evidence that the district health system is committed and supports the implementation of IMCI and would like the process of improving district supervision to take place.

Health Facility level

• Procedures in all health facilities have changed in favour of implementation of IMCI and improvement of services in general. Those that have not changed are willing and ready for changes.
• There is readiness for health workers who are not trained to share tasks with good quality after orientation from trained health workers. Equipment and drugs have been made available by supplementing health facilities with EDP kit drugs including those needed for IMCI, STD and HIV prevention, family planning, malaria management, Insecticide Treated Nets and TB/Leprosy drugs in some health facilities.

Health worker skills

Health worker skills have improved in relation to management of the sick child, STD and HIV prevention, Family Planning, Management of malaria, cost tracking and some in the knowledge about the INDENT system. This is due to the training sessions that took place in 1998 related to the mentioned interventions in the district.

Rational drug use

IMCI information collected though special forms indicate that trained health workers who are practicing the learnt skills have good rational drug use attitudes. This can be easily reflected in their well kept records. The majority of health workers visited are practicing rational drug use. That is using the right treatment correctly for a particular illness.

Interaction with the community

Interaction with the community is very good especially for those who have been in contact with health workers in the facilities during illness of their children mothers appreciate the improved services being provided.

Problems

Among problems that surfaced is the overlap of activities in the district health plans including supervision plans and schedules. Planned activities schedules were not adhered to due to various reasons. DHMT is overburdened by other activities like training, supervision, planning administrative issues, leave and other unavoidable circumstances. With regard to supervision some health workers are not visited for very long periods by the DHMT. Distances from the central district level to some health facilities are long and the roads are off often not passable.

Encouraging signs of a new approach

It is about two years since the implementation of TEHIP started in earnest. The period is somewhat too short to take stock of achievements or failures. In a recent visit to the project area, <U>TEHIP News</U> had a chat with health workers and patients on the impact of the project in the delivery of health services. The following are excerpts from their perceptions;

Tarsis Bwakila, Clinical Officer, Ikwiriri Health Centre:

"TEHIP has contributed enormously in terms of training and improving health services and care. I am impressed with the achievements in attending the under-fives, we have most of the drugs for common disease and the way of managing diseases has improved. Now we take more time to address patients complaints. A good indicator of improved services is the increasing number of patients coming to our facility."

Shadrack Bushiri, Kibiti Health Centre, Rufiji:

"I have been at the Centre for one year now but I am no stranger to the district's health facilities. I have been working in this district since 1980 and I can easily assess the impact of the TEHIP. We now attend about 150 patients daily compared to 30 to 40 when we used to receive only the Essential Drugs Kits. More patients are coming to us because they know they will be attended well and get the prescribed medicine. We even give some patients appointments to visit us after two days to check their progress. The various courses provided to health workers have been fruitful."

Wilfred Matee, District Nursing Officer and DHMT member, Morogoro Rural:

"It is evident that TEHIP has enhanced coordination in the delivery of health services. Before TEHIP implementation, coordination and communication even among members of the DHMT was limited. With the take off of the project we have witnessed improvement in supplies, infrastructure and even more support from the local administration."

Asha Rajabu, Clinician, Ntombozi Dispensary, Morogoro Rural:

"I have been working in this dispensary for the past 10 years and I've seen great changes since TEHIP activities became operational. There are more drugs especially for under-fives compared to previous years. We were using a rundown building erected in 1930s, now the facility has been renovated and we are happier to work in such a facility."

Amadeus Mwananziche, Medical Assistant In-charge, Mlali Dispensary, Morogoro Rural

"I have worked here since 1995 and the changes are clear. In the past one year or so we have been receiving supplies of medicines especially for under-fives. Adults supplies have also increased because what we don't use for children increase stocks for adults. The training which we received in MCI and other areas has helped us a great deal in the management of various diseases. I guess mortalities have been reduced in this area. Since January this year (Interview conducted on April 14, 1999) only one infant died."

Dr. Ferdinand Fupi, Regional Medical Officer, Morogoro Region:

"I am grateful having the project here. Delivery of health services and care in Morogoro Rural District is unparalleled in the region's districts. The district has been able to write a comprehensive health plan. Plans of operation now exist and are monitored. There are many changes that are explicit, for example, the DHMT capacity has been enhanced; support in terms of funds, transport, and communication means, hence articulated, elaborate data collection that facilitates early warning of outbreaks, and rehabilitation of facilities. There is community involvement going with the changes hence there is no doubt of the benefits and efficacy."